Posts or Comments 20 June 2024

Monthly Archive for "May 2010"

Advocacy &Integration &Performance Bill Brieger | 31 May 2010

Can International Institutions Change Government Behavior?

A headline in BBC News today reads, “International Criminal Court ‘altered behaviour’ – UN.” United Nations Secretary General, Ban Ki-moon was quoted saying, “In this new age of accountability, those who commit the worst of human crimes will be held responsible.”

These comments were made at the opening of a ‘stock-taking’ conference of ICC impact on justice for Victims opening today in Uganda. A discussion paper for the conference concludes that …

By engaging victims in trial proceedings, reparation programs, and outreach activities, the Court not only acknowledges and recognizes their suffering and losses, it also helps to make proceedings in The Hague more relevant to communities affected by mass violence. Indeed, if done in a meaningful and consultative way, formal recognition of victims, coupled with effective outreach programs, can help cultivate a sense of local ownership of ICC proceedings and lay the groundwork for greater acceptance of facts established by the Court’s judgments. Such efforts can also help reduce the likelihood of future conflict and strengthen a tenuous peace.

Importantly, the same most common victims of mass violence addressed by the ICC are those most affected my malaria – women and children. And the displacement experienced by these groups in fact heightens their risk of exposure to malaria. As has been reported from eastern DRC.

pbf3.jpgOne wonders whether international institutions like the Global Fund to fight AIDS, TB and Malaria has a similar impact on accountability. The mechanism for this potential impact is ‘Performance-Based Funding.’ According to the Global Fund …

Performance-based funding ensures that funding decisions are based on a transparent assessment of results against time-bound targets … Today, the performance-based funding model is used by a number of development organizations and initiatives (including the GAVI Alliance, the Millennium Challenge Account and the European Commission) as a way to ensure the accountability, efficiency and effectiveness of programs being funded.

GFATM grant reviews rate projects according to progress toward their own stated objectives. All this information is publicly available for scrutiny. The following examples where changes resulted from progress ratings are given by GFATM:

  • Mali,HIV (Rated B2): Procurement bottleneck identified; UNDP and UN provided technical support to build local capacity.
  • Ethiopia, Malaria (Rated B2): Government focused on problems and sought technical support from UNICEF; grant became A-rated and delivered ten million insecticide-treated bed nets to protect people from malaria.
  • Senegal, Malaria (Rated C): Grant stopped, Country Coordinating Mechanism reformed, civil society involved, and new grant signed which proved successful. Country benefited from clear performance evaluation, even with a C-rating.
  • Nigeria, HIV (Rated C): Grant stopped, rebuilt monitoring and evaluation system and new grant signed which proved successful. Country benefited from clear performance evaluation, even with a C-rating.

There are also examples where the accountability process resulted in grant suspension when financial improprieties were discovered, as happened in Uganda. A transparent, highly visible system of accountability is necessary, not only to preserve human rights generally, but also specifically to strengthen the right to basic health services including malaria control.

Policy &Resistance &Treatment Bill Brieger | 30 May 2010

Strong words against oral artemisinin monotherapy drugs

Forty-four Ministers of Health of the African continent (as well as Brazil and India) or their representatives congregated at a special ministerial session of the 18th Roll Back Malaria (RBM) Partnership Board meeting and on the last day, 14th May 2010, signed a document in which they, “Express(ed) our governments’ engagement, with support from our development partners, to eliminate (ban and enforce) oral artemisinin-based malaria monotherapies and substandard ACTs from the market through tangible policies, strategies and regulatory measure within the next 12 months.” Hopefully these words will lead to action and soon.

art_drugs_sm.JPGThe World Health Organization has been pressing this issue strongly for several years, and as far back as 2001 a WHO publication, “Use of Antimalarial Drugs” (pg. 72), specifically stated that artemisinin should preferably be administered in combination with another effective blood schizonticide. A press release in early 2006 WHO called for an immediate halt to provision of single-drug artemisinin malaria pills, and was issued in concert new malaria treatment guidelines issued by WHO.  In another press release later in 2006 WHO announced that some pharmaceutical companies agreed to stop marketing single-drug artemisinin malaria pills, specifically the press release explained that …

“In January 2006, WHO appealed to all companies to stop marketing oral artemisinin monotherapies and to re-direct their production efforts towards ACTs. Following the January appeal, an additional 23 companies were identified and informed of WHO’s recommendation. 13 companies said they would comply with the WHO guidance. Additional companies have said they are willing to collaborate with WHO in this endeavour.”

It is not clear that WHO’s warning was heeded, because another WHO press release on 25 February 2009 stated that, “WHO today said that the emergence of parasites resistant to artemisinin at the Thai-Cambodia border could seriously undermine the success of the global malaria control efforts.” While outright resistance was not declared, Dondorp and colleagues found in 2009 that, “P. falciparum has reduced in vivo susceptibility to artesunate in western Cambodia.”

Reuters reported earlier this year that, “Pailin (Cambodia) is the origin of three drug-resistant malaria parasites over the past five decades. Thanks to prolonged civil conflict, dense jungles and movement of mass migrants in the gem mines in the 1980s and 90s, the strains multiplied and dispersed through Myanmar, India and two eventually reached Africa.” The situation is made worse by illegal pharmacies that sell counterfeit medicines. MediaGlobal stated earlier this month that, “the government (of Cambodia) has shut down 65 percent of illegal pharmacies. The number of illegal pharmacies has decreased from 1,081 in November 2009 to 379 in March 2010.”

Action by the 44 African Ministers of Health is not too late, but it could have come sooner. The Ministers pledged to “Report on progress in eliminating oral artemisinin-based monotherapies in May 2011,” as they signed up “to the commitment against the use of oral artemisinin-based monotheraples for malaria control.”

Nigeria, with the highest malaria burden in Africa, was one of the countries that apparently missed the meeting. Onwujekwe and co-researchers recently documented the sales or provision of monotherapy artesunate drugs in most of the public and private hospitals as well as pharmacies they studied in Anambra State. Nigeria’s policy concerning monotherapy artemisinin drugs was to all those already on the market to continue until their license ran out.

As we reported previously, some of those licenses will not expire until 2012.  We hope Nigeria and all other malaria endemic countries will act sooner than later and be able to report the complete removal of monotherapy artemisinin drugs my May 2011.  We want to eliminate malaria, not eliminate the effectiveness of ACTs.

Integration Bill Brieger | 28 May 2010

Tropical diseases need an integrated approach

A common critique of the Global Fund to Fight AIDS, TB and Malaria is that there are other major contributors to the burden of disease in tropical countries.  Some are infectious like pneumonia while others are non-communicable like injuries.

dscn1225sm.JPGFrom the standpoint of malaria, integration makes sense. From the start, the Roll Back Malaria Partnership made it clear that malaria control (end eventual elimination) could not succeed unless health systems were strengthened. These are the same systems that are supposed to control filariasis, helminthic diseases, diarrheal diseases, and pneumonia as well as promote maternal health, child growth and development as well as immunization programs. It was a weak health system that contributed to the failure of the first effort to eradicate malaria fifty years ago.

Two recent articles exemplify the need for integrated prevention and control services because tropical communicable diseases themselves are ‘integrated’ into the environment and the human host.

Abraham Degarege and colleagues examined Malaria and helminth co-infections in outpatients at Alaba Kulito Health Center in southern Ethiopia. Fifty-four percent of patients having malaria parasites also had at least one of three helminth infections including hookworm, A. lumbricoides and/or T. trichiura. Those with both worms and malaria (P. falciparum and/or P. vivax) had higher rates of anemia. These negative synergies require an integrated approach to patient management as well as to community prevention programs.

Marcia C. Castro and her co-researchers looked into local water sources for larval development of lymphatic filariasis and malaria vectors in Dar es Salaam, United Republic of Tanzania. Larvae of both anopheles and culex species were found in puddles, swamps, mangrove swamps, drains/ditches, human-made holes, water storage, agriculture, rivers/streams, and ponds.

Polluted urban environments are less conducive to anopheles breeding, and culex were more likely to be found in all these urban sites in Dar es Salaam, especially in drains/ditches, but again in this environment both types were found, meaning that both filariasis and malaria ‘co-existed’. Integrated control through larviciding and ITNs would help prevent both diseases.

If basic health services are well funded, staffed and supplied, no tropical disease needs to be neglected.

Environment Bill Brieger | 23 May 2010

Should the Malaria Community Warm to Climate Change?

According to the BBC, “Reports from northern Nigeria say a growing number of people from Niger are crossing the border into Nigeria because of the food crisis at home. A BBC correspondent in the northern Nigerian state of Katsina says many women and children from Niger are seeking shelter with local families.” Although Niger has experienced droughts and famine before, such events are expected to become more frequent as the globe warms.

A recent article by Peter Gething and colleagues has basically sought to de-link the notion that climate change is synonymous with increased malaria transmission, and the Niger example may be a case in point. While there have been examples of warming leading to increased malaria transmission in the East African highlands, analysis by Gething’s group shows that overall, human efforts through recent massive control interventions are more of a factor in influencing a downward trend, than climate change could push transmission upwards.

eritrea-007a.jpgA drier environment that produces these famines is also less conducive to mosquitoes and malaria transmission. This, of course, is not the type of trade off one wishes in order to achieve malaria control targets.

The question of greater interest is whether the global community will continue to fund malaria control efforts and increase that funding so that climate change or any other factor will not stand in the way of malaria elimination?

Johan Rockström and colleagues address the question of economic growth and its impact on climate change and the environmental tipping points beyond which life as we know it may no longer be possible. If we move to a no growth scenario, will there still be funding to fight the major killer diseases? Will we put the breaks on climate change and yet forfeit progress on malaria control due to lack of funding?

Much depends on our priorities. Are we willing to stand up for a world that is saved from the environmental degradation caused by unlimited growth as well as one that is free from malaria?

Funding Bill Brieger | 19 May 2010

Can large scale disease control programs be sustained?

Roll Bank Malaria (RBM) was launched in 1998, but actual scale up to universal coverage is only happening in 2010. By Comparison, the African Program for Onchocerciasis Control (APOC) took off in 1996 and has been scaled up for several years in all but a few of its endemic countries. Granted, APOC has a relatively smaller target area, but it now regularly reaches over 127,000 African villages with annual doses of ivermectin.

Both programs have in common the need to sustain their scaled up for many years into the foreseeable future if disease elimination is to be achieved.

This need for a long term perspective causes concern when one reads about a threat to continued funding for APOC’s Borno State, Nigeria project, and raises speculation whether malaria efforts may face the same threat a few years down the line.

buea4sm.jpgAPOC started with a very clear vision of sustainability. APOC, a government entity (state, province, district, or country) and a non-governmental development agency (NGDO) would enter into a financial and programmatic 5-year partnership to establish community directed treatment with ivermectin (CDTI – see photo of CDTI in Cameroon at right). APOC’s financial contribution would be largest in the first year, when the overall budget would be largest because of start up costs.

Over time, program costs were to reduce, as would costs per person treated because of economies of scale. APOC’s share of the budget would decrease relative to that of the government partner, though the overall budget to maintain the program into the future was expected to be smaller and more manageable to the government partner with some continued support from the NGDO.

Free supplies of ivermectin from the Mectizan Donation Program would continue as long as there was need, but by the sixth year of operation, it was hoped that countries could sustain their own CDTI efforts. Apparently this has not been easy.

Evidence of problems with Borno’s CDTI project surfaced in 2007 at a meeting of APOC’s Technical Consultative Committee where the following report was shared. “Borno has maintained a good geographic and therapeutic coverage. However, the project has the following challenges:

  • Non-release of funds by state and LGAs
  • Inadequate number of FLHF staff
  • Selection and training of more CDDs
  • Obtaining funds from the government

IRIN now reports that after 11 years of operation “The (Borno State) government was supposed to provide counterpart funds to run the river blindness programme, but it has not done so, (according to) Borno State’s onchocerciasis coordinator Galadima.” Hellen Keller International (HKI) is Borno’s NGDO partner for CDTI and has been trying to make up the slack.

Unfortunately “HKI funding has been hit by the global recession, says (a representative). ‘Since the recession our donors have turned their attention elsewhere with little consideration for Africa and this affects the volume of funds for intervention projects like the onchocerciasis.’

Project staff complained to IRIN that, “We have been crippled financially due to lack of state counterpart funding. We sometimes find it hard to fuel our vehicles and go for supervision in the affected communities.”

There were hopes that another four years of government funding would put Borno within reach of elimination goals, but project staff lament that, “If the project stops at this stage, the effects will be devastating. It will turn the tide of the success we have achieved which will be quite disastrous.”

Let’s move this scenario forward to 2015 and change the disease to malaria. Let’s assume that talk of funding ceilings by donors has become a pressing reality and countries need to contribute more to sustain malaria interventions and achieve elimination. Let’s hope we don’t wind up again like malaria control did in the 1950s and ‘60s – eliminating the programs, not the disease.


ps – The IRIN article does have some potential technical problems. It referred to the CDTI as a program to create ‘immunity’  to onchocerciasis, whereas ivermectin actually is a drug to kill the microfilaria of the parasite and keep infection at a low level until such time as adult worms die and transmission in the community stops. There is also concern about the figure of $18 per person treated. Normally at this advanced stage of the program we should be talking in terms of cents, not dollars. These technical problems with the article do not detract from its serious financial message.

Diagnosis &Treatment Bill Brieger | 09 May 2010

Update on Malaria Management in Nigeria

2010-seminar-of-malaria-society-of-nig-sm.jpgThe Malaria Society of Nigeria is planning a seminar to update members and those concerned about controlling malaria in the country on management of malaria. The event will take place at the Nigerian Institute for Medical Research in Yaba, Lagos, on 12 May 2010 at 10 a.m.

There are many aspects to managing malaria, but to take only one – case management – is a challenge in itself.  The National Malaria Control Program‘s 2010 annual workplan outlines five key activities that need to be accomplished in order to properly treat a person who has suspected malaria:

  • Parasitological confirmation of malaria cases by rapid diagnostic tests (RDT) and scaling up of diagnosis by microscopy
  • Treatment of uncomplicated malaria with an ACT within 24 hours of fever onset through all health care providers (public and private)
  • Expansion of access to free ACTs to community level through local human resources
  • Early recognition and improved management of severe malaria cases
  • Drug efficacy and quality monitoring

To this we should add ‘counseling’ of those receiving ACTs to ensure adherence to the full course of treatment.  As a recent Malaria No More posting noted, “The only pill that works is the pill that’s swallowed.”

The current national malaria treatment policy, guidelines and training materials were adopted in 2005. While these are technically correct in terms of stressing ACTs, but there is still a reliance on clinical or symptomatic diagnosis. While parasitological diagnosis is addressed in the current workplan, it also needs to be disseminated in easy to read guidelines and training materials.

Much has changed in the five years since the last malaria treatment policy and guidelines were adopted including the pressing need to use rapid diagnostic tests in primary health care facilities, the huge multiplication of brands of ACTs on the market, the impending large scale roll out of home management of malaria through community volunteers and patent medicine vendors, and related to the latter, the award of a pilot Affordable Medicines Facility (malaria) grant.

2008-nigeria-dhs-malaria-treatment-2.jpgThese changes are built on an unsteady foundation as documented in the 2008 Demographic and Health Survey. Three years after the national treatment policy had been updated, ACTs were very rarely reported in malaria treatment, as seen in the chart.

An ACT Watch survey in December 2008 of 468 medicine outlets (public and private) found that only 16.7% had the national firstline ACT – artemether-lumefantrin.  In all cases, the most common antimalarials in stock were non-artemisinin drugs.

Increased malaria funding for Nigeria from the Global Fund, DfID, USAID and the World Bank Booster Program should make ACTs and RDTs more readily available if supply and distribution systems are strengthened. This will only be effective if health professionals understand the national malaria treatment policy and the case management implications of proper parasitological diagnosis. We hope that the Malaria Society’s upcoming seminar can contribute toward this goal.

Funding &ITNs Bill Brieger | 02 May 2010

Ceilings, Doors and Floors

Is the malaria house in order? NGOs worry about donor funding ceilings that affect their own funding floors, agencies distributing nets need to unlock store room doors and net recipients look at their ceilings and wonder how to hang their nets. This is some of the news that threatens success of efforts to achieve universal coverage.

One man’s ceiling is another man’s floor – so the saying goes. One would hope that support from the Global Fund, The World Bank, US Government and DfID, among others, would be a sturdy floor or foundation on which governments in endemic countries could build a strong malaria control program.

It becomes evident reading an article posted at World Sentinel that if donors to the Global Fund actually succeed in setting funding ceilings, the financial floor to control malaria in endemic countries will become less stable. Specifically, “NGOs are outraged at developments of the current Board meeting of the Global Fund Board to Fight AIDS, Tuberculosis and Malaria, taking place in Geneva, Switzerland. Many donor governments are promoting the establishment of a ceiling on the next round of disease fight grants to developing countries.”

This ceiling would stifle innovation, dampen country ambitions and cost lives according to the Global AIDS Alliance. We have discussed concerns that not all endemic governments are making a serious financial commitment to malaria control, and if the donors’ ceiling drops and their own floor falls, who will make up the funding gap?

dscn2551-sm.JPGAn equally frightening part of the ‘malaria house’ becomes evident “even as donations roll in and millions of bed nets pile up (behind the doors of) warehouses across Africa, aid agencies and non-governmental organizations are quietly grappling with a problem.” But even when these nets are released, they may not be used.

“Data suggest that, at least in some places, nearly half of Africans who have access to the nets refuse to sleep under them,” according to the Los Angeles Times. Why are nets not hanging from all ceilings?

The LA Times article gives some reasons why villagers won’t hang nets in their houses: perceived poor ventilation when sleeping under nets, not being sure how to hang them over sleeping mats, and not viewing malaria as a serious enough threat to warrant the inconveniences of hanging and using one. Clearly education on net use has not often gone together with getting the distribution numbers higher. As Sonia Shah says, nets may be “‘gifts’ that many neither want nor use.”

Maybe if we convince donors and governments that nets and other malaria commodities are being used, they will remove their funding ceilings and give us a chance to eliminate malaria from all houses in endemic countries.